| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam_hydration.v0 |
|---|---|
| Concept | Hydration |
| Description | Findings observed during assessment of the hydration status of an individual. |
| Use | Use to record a narrative description and clinical interpretation of the findings observed during assessment of the hydration status of an individual. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element.observed during assessment of the hydration status of an individual. |
| Purpose | For recording a narrative description and clinical interpretation of the findings observed during assessment of the hydration status of an individual. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2007-03-12 |
| Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2007-03-12 |
| Other Details (Language Independent) |
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| Keywords | |
| Lifecycle | in_development |
| UID | 3ef892f3-cc76-4465-b0b7-74a78574a1c6 |
| Language used | en |
| Citeable Identifier | 1246.145.2813 |
| Revision Number | 0.0.1-alpha |
| items | |
| Clinical description | Clinical description: Narrative description about the individual's state of hydration. |
| Mucous membranes | Mucous membranes: Narrative description about the state of all mucous membranes, including mouth and lips. |
| Anterior fontanelle | Anterior fontanelle: Description about the state of infant's anterior fontanelle.
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| Skin turgor | Skin turgor: Description about the state of the individual's skin or tissue turgor.
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| Appearance of eyes | Appearance of eyes: *
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| Examination findings | Examination findings: Structured details about indicators of hydration. For example: thickness of saliva. Include: openEHR-EHR-CLUSTER.exam_ |
| Multimedia representation | Multimedia representation: Digital image, video or diagram representing the physical examination findings. Include: openEHR-EHR-CLUSTER.multimedia.v1 and specialisations or openEHR-EHR-CLUSTER.multimedia.v0 and specialisations |
| Clinical interpretation | Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. |
| Comment | Comment: Additional narrative about the physical examination findings, not captured in other fields. |
| Examination not done | Examination not done: Details to explicitly record that this examination was not performed. Include: openEHR-EHR-CLUSTER.exclusion_ |
| Other contributors | |
| Translators |